Whether you are tracking something for PCMH, Meaningful Use, pay for performance, or another program, you can use an order in PCC EHR to record medical information.
Orders in PCC EHR include medical procedures, screenings, labs, referrals and any other work done on behalf of a patient. By creating the right kind of order, adding the correct SNOMED-CT codes and LOINC tests to your orders, and configuring your protocols so the orders appear on chart notes, you can make it easy for your clinicians to meet the requirements of any CQM or other mandate rule.
In the examples below, we configure PCC EHR to meet the requirements of NQF 0418: Depression Screening, a Clinical Quality Measure used for PCMH and other mandate programs. (For more details about CQM requirements, read How to Chart for Each Clinical Quality Measure.) You can follow a similar procedure to configure PCC EHR to meet other reporting standards.
- 1 Create Your Practice’s Orders (and Add Tracking Codes)
- 2 Add Orders to Your Custom Chart Notes
- 3 Configure Billing Codes for Your Screenings, Procedures, and Other Orders
- 4 Chart the Visit, Use the Orders
- 5 Achieve One-Click Reporting By Removing the Default Task
- 6 Remember to Bill the Visit and Perform Other Steps
Create Your Practice’s Orders (and Add Tracking Codes)
For tracking data for any kind of measure, you’ll need a screening, medical procedure, or some other kind of order. Follow the steps below to learn how to create (or edit) an order and add required tracking information for a CQM, Meaningful Use Measure, Pay for Performance report, or other mandate.
Open the Protocol Configuration Tool
Click on the Tools menu and select Protocol Configuration.
Open the Component Builder
Click Component Builder on the Protocol Configuration tool window.
Open the Appropriate Orders Component
Double-click on one of your Orders component to add or edit an orders.
Orders components include Screening Orders, Medical Procedure Orders, and so forth. They all end with the word “Orders” to make them easier to find.
Edit or Add an Order
Click “Add” to create a new order, or double-click on an existing order to make changes.
Your practice can have one or more orders that meet the same mandate or workflow need for your practice. For example, for depression screenings you might have different orders for a PHQ-9 and for other types of screening and followup.
Configure Basic Order Details
Review the order name and set any other configurable options. For example, you may want certain orders to be private by default, in which case you would deselect the “Include on Patient Reports” option.
Review or Add SNOMED-CT Procedure Codes for Tracking
Some measures are tracked by the use of specific SNOMED-CT procedure codes. Search and add the appropriate procedure.
When a patient has a positive result on a depression screening, your practice might perform a suicide risk assessment screening order. That order is tracked with SNOMED-CT procedure in order to report on a Clinical Quality Measure.
Edit the relevant Orders component and order, and then add any appropriate SNOMED-CT Procedure codes.
For example, for a suicide risk assessment screening order, you could add 225337009, “Suicide risk assessment (procedure)” to the order. You could also add codes to followup orders, such as Completion of a Mental Health Crisis Plan, Coping Support Management, or other mental health evaluation or treatment.
Some measures, such as the depression CQM, track referrals. Referrals are also tracked with Referral Orders component orders and a SNOMED-CT Procedure description.
For example, you may have referrals for an initial psychiatric evaluation or a specific depression referral.
For information on which SNOMED-CT descriptions to use for each type of order, refer to your state or officiating agency’s requirements for tracking data for a report. For tips on recording information fro each CQM, read How to Chart for Each Clinical Quality Measure.
Review and Add Tests (LOINC codes) for Tracking
Some measures are tracked by the use of a specific, standardized test. Search and add the appropriate test that you perform, and adjust test options.
Tests are identified with a unique LOINC code.
What Tests Should I Add?: The specific test you should add depend on what your practice performs and on the requirements of the mandate you wish to track. For example, for an initial depression screening, you might add 73831-0, “Adolescent depression screening assessment” or 73832-8, “Adult depression screening assessment” for an order for patients 18 years or older. The tests should have a Negative/Positive result. You can also add more than one test to a single order. For example, if you perform a PHQ-9 at each visit, you might first add the “Adolescent depression screening assessment” test, which is used by the clinical quality measure, and then also add the “Patient Health Questionnaire 9 item (PHQ-9) total score” test in order to record the patient’s numerical result.
Repeat for Other Orders that Meet the Same Measure
Your practice may have more than one order that meets the same measure. Click “Add” to create new orders, or double-click on existing orders to make changes. Repeat the steps above to configure the order, and add the appropriate LOINC tests or SNOMED-CT description.
Add Orders to Your Custom Chart Notes
After you make changes to the various orders your practice uses, you can add them to chart notes to make them easier to order. Your clinicians will then see the “Depression Screening” order, for example, on every chart note.
While this step is optional, you can make it more likely that your doctor will complete the required order by making it easier to order when they are charting a visit.
Open the Protocol Configuration Tool
Click on the Tools menu and select Protocol Configuration.
Open the Protocol Builder
Click Protocol Builder on the Protocol Configuration tool window.
Edit a Chart Note Protocol
From the list of Chart Note Protocols, select the first one that could be used for a patient that a measure intends to track. For the Depression example, find the first chart note protocol that would be used for a patient aged 12 years or older. Double-click to edit it.
Edit (or Add) the Orders Component
From the list of components that appear in this chart note protocol, find the relevant orders component (Medical Procedure Orders, Screening Orders, Referral Orders, etc.) and double-click to edit it. Or, click “Add” and select the component to add it to the protocol.
Add the Specific Orders
Click “Add Items” and select the appropriate orders that you wish to track during that type of visit. For example, select the Depression Screening and any other appropriate screening orders in order to make it easier for your practice to use that order during that type of visit.
Repeat For Referrals or Other Orders
Optionally, add other screenings, referrals, or other orders. You might also want to add orders that could result from a positive screening, for example.
Repeat For Each Chart Note
You should repeat the above steps for every chart note, adding appropriate orders that you wish to track during the related visit.
Configure Billing Codes for Your Screenings, Procedures, and Other Orders
Some performance measures and incentive programs track results by billing codes. How can you make sure that the correct billing codes show up when you perform a Fluoride Varnish, or use some other order to track clinical activity?
Use the Billing Configuration tool to set up the correct billing codes for your orders.
Open the Billing Configuration Tool
Open the Billing Configuration Tool in the Tools menu in PCC EHR.
On the “Order Mapping” Tab, Find Your Order
Use the Search field to find the order you wish to configure for billing. Double-click to open the order.
Enter the Billing CPT Code for the Order
Under the CPT Billing Procedures section, enter one or more codes for the order. You can set the codes to be automatically selected on the electronic encounter form, or you can set them to appear as optional codes for the clinician or biller to select later.
What About Billing Diagnoses (ICD-10)?: On this same screen, you can added optional ICD-10 Billing Diagnoses. They will then appear on the Bill screen whenever someone orders this order for the patient. However, this should be rarely used. Diagnoses should be charted on a chart note and not added in Billing Configuration. For example, for a Fluoride Varnish, the appropriate diagnosis code is sometimes the standard well visit code (Z00.129), which the clinician selects on the chart note.
What if I Can't Find the Procedure?: If you are configuring a new procedure that your practice has never billed before, you may need to update your practice’s list of procedures. You can do so in the Procedures table of the Table Editor (
ted). Contact your Client Advocate for help.
Save Your Changes and Test Your Order(s)
After you’ve reviewed and updated the required billing code for an order, click “Save” and repeat the process for all orders that you need to review in order to meet your reporting needs. Then, create a visit for a sample patient and try them out! Whenever you create an order on the chart note, the correct corresponding codes should appear on the Bill screen.
Chart the Visit, Use the Orders
After you have completed the above configuration, your practice’s clinicians can track the completion of a screening, medical procedure, or other order with a single click.
Optionally, the clinician can assign the order to another clinician, or complete the screening immediately. If the screening is refused, they can select “Refused”. If the screening is contraindicated, they can select “Contraindicated” and enter an appropriate contraindicated diagnosis in the Diagnoses component on the chart note.
When the screening is complete, they can enter a result in the order.
Unless refused or contraindicated, a positive or negative result is often required to track a measure. The result interpretation, in the Interpretation field, is not required for Clinical Quality Measures, though your practice may configure an order to require it.
If a test result is positive, record whatever additional care follows.
For example, you may prescribe appropriate medication, order a Suicide Risk Assessment or order a referral.
Enter results and take any other appropriate followup steps.
Achieve One-Click Reporting By Removing the Default Task
By default, orders have a single incomplete task. If you clinicians remove that task, they can trigger the order (and track data for the measure) with a single click.
First, click Order and then click Edit to edit the order.
Next, blank out the default task on the order and click “Save Order”.
For the clinician who removed the task, there will no longer be a task that needs completion for the order to be tracked as complete.
Remember to Bill the Visit and Perform Other Steps
When orders are complete and a visit is ready to be billed, make sure someone at your practice confirms the provider of the encounter. Many mandates or incentive programs require reporting based on a provider.
Next, the provider should click “Bill” and select an appropriate visit encounter code. In addition to billing, the visit encounter code is used to track data for Clinical Quality Measures and many other reporting features in PCC EHR.